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Community Integrated Paramedicine
Community Integrated Paramedicine: What can we
do for you?Kristine Kuhl
Community Paramedic Coordinator
MDHHSBureau of EMS, Trauma and Preparedness
The Evolution of EMS
1966 white paper titled “Accidental Death and Disability: The Neglected Disease of Modern Society.”
From Emergency to Critical Care (Inter-facility)
Utilization in episodic, non-acute, out of hospital care
1990’s point of care testing and telemedicine – game changer
2001 – Community Paramedicine -Improving Rural Healthcare
What is this thing?
• Community Paramedicine (CP) • Healthcare delivery model • Increases access • Specially trained EMS providers • Expanded role• Must have partners
• Fill gaps/safety net• Integrated Care – connecting dots• Triple Aim
What Community Paramedicine is NOT
Replacement of existing services
Competition
Duplication of services
International and National Scene
England, Australia, Canada, Scotland, United States
• 2005 - 50 delegates – Australia, Canada, Scotland and United States
• Rural focus
International Roundtable on Community Paramedicine
• National Association of State EMS Officials• National Organization of State Offices of Rural Health• Center for Leadership, Innovation and Research in EMS
Community Paramedicine Insights Forum (CPIF)
• Legislation first• Pilot studies first• Committee assembly
Currently 36 states in ‘some form’
What is Michigan doing?• 2 Years• Strategic Plan
• CP Certification• Standard Outcome
Measurements• Toolkit• Policy and Administrative
Rule Changes• Grants
Colorado
Western Eagle County Health
Services District (WECAD)
Rural resort community –
54,000
2 hours west of Denver – extreme
weather
30% residents uninsured
54% ambulance patients uninsured
Goal – Proactive to prevent
ambulance transport
Services Offered
Hospital discharge follow-up
Medication reconciliation Blood draws
Home safety checks Social assessment Nutritional
assessment
Well baby/child checks
Blood pressure and oxygen saturation
Post-injury/illness follow-up
Illness/medication education and
compliance
Results• Patient profiling was done based on Eagle County Community Paramedic
visits from January 2015 to December 2015. Results showed:• 52 patients were served• 146 visits were provided• Patients were seen 1-5 times
• Higher Level of Service Utilization Prevented:• 142 doctor visits• 26 emergency room visits
• Initial Cost Savings:• $1,969 average savings per visit• $280,000 total healthcare costs saved in 12 months
• https://www.ruralhealthinfo.org/project-examples/786
Minnesota
First in the nation to certify Community Paramedics - July 2012 (20)
Grant from the Department of Labor
Recognition of CP as a provider in law
Certification for payment model discussion
Community Paramedic Curriculum: Past, Present and Future
2009
Version 1.0• Minnesota Pilot
Project• Classroom setting
2010
Version 2.2• Colorado Pilot Project• Classroom/Online
2011 & 2012
Version 2.2• Minnesota – Round 2
& 3• Hennepin Technical
College
California
November 14, 2014
Mobile Integrated Health – Community Paramedic
Office of Statewide Health Planning & Development approved California Emergency Medical Service Authority to establish a Health Workforce Pilot Project
California – 7 concepts
Post-Discharge, Short-term Follow-Up:
Frequent EMS Users
Directly Observed Therapy for Tuberculosis
Hospice
Alternate Destination – Mental Health
Alternate Destination – Urgent Care
Alternate Destination – Sobering Center
DOT
• Ventura County – Public Health + TB Clinic + CP• 6 to 9 months of treatment• Assigned Patients
• Resist treatment• Verbally abusive• Sexually inappropriate
• TB Clinic – 722 missed doses (6.7%)• CP – 2 missed doses (0.06%)
Michigan – Special Studies
• Muskegon• Clinton Area Ambulance
Service Authority (CAASA)• Henry Ford Health
System- Superior• Tandem 365 – Life EMS• Livingston County EMS
• Medstar Macomb• Hayes Green Beach• RSVP-Bloomfield
Township Fire Dept & Star EMS
• Emergent Health Partners (EHP)
• JCA & HVA
Muskegon Program
• June 21, 2016• ProMed, White Lake Ambulance
Authority, Oceana EMS
• Mercy Health/Mercy Health Hackley
• West Michigan Regional Medical Consortium (WMRMC)
• Reduce hospital re-admissions post discharge and help with transition of care from hospital to Primary Care Provider
• Strokes and Trauma• Case Management, sub-acute
rehab, nursing home/rehab
Muskegon Wins
•Matter of Balance Instructors•CVA/TIA Diagnosis (June-June)
•2015/2016 Inpatient readmissions: 56% • (N-1378)
•2016/2017 Inpatient readmissions: 13% • (N-1847)
CAASA Program
• To provide quality and compassionate care in the home environment in partnership with the patient, caregivers, and their primary care provider to allow for the highest quality of health and life possible.
• Anyone identified as in need of services
• Local PCP’s, Pathway (local health department), DHHS Adult Protective Services, local critical access hospital, EMS crews
CAASA Wins
•1 Patient 2016: 48 ambulance transports and 65 Emergency Department visits
•Quarter 1 2017: 0 and 0
Henry Ford:Superior
• January 01, 2016• Post discharge
support, readmission prevention, PCP engagement
• CHF, COPD• In-patient case
management
Unique
• HFHS MIH/CP Program• Training Program• Health Plan• Emergency Department• Physician• Integration and Communication• 30 day readmission
Medstar Macomb
•Medstar – Texas•Mobile Healthcare Program
•9-1-1 Nurse Triage
•Data Masters
Medstar Macomb Wins
•QTR 1 2017: •Reduced readmissions of enrolled patients from >20% to 3%
Tandem 365
• May 14, 2014• Life EMS• Kent, Ottawa, Allegan,
Kalamazoo permission- 1 Tandem Medical Director
• “A community collaboration empowering others to achieve better health, reduce costs, and improve quality.”
• 55 and older (typically) who require assistance managing complex medical problems
• Insurance plans – Priority Health
Tandem 365
• Integrated Care Paramedics (ICP’s) • Document in an electronic medical records system• Conversations are logged through a three way call with a voice logger
to record the conversation• Involved in daily interdisciplinary team (IDT) discussions • Summary reports are provided to Medical Control Directors. • No new skill set is implemented without medical director knowledge
and approval.
Emergent Health Partners (EHP)Community Paramedic Programs
Huron Valley Ambulance (HVA) –
August 2015
Jackson Community Ambulance (JCA) -
March 2016
The program mission is to focus on ER diversion
and readmission prevention
EHP Discoveries and Wins
• Efficiency• Dispatch Center• 10-12 patients/24-
hours• Quarter 1
• 849 patient contacts
• Potential Patients Identified
• 8,000 year• 22 day
Community Paramedic Work Group
• Meets monthly• Every other month –
general CP Work Group• Alternate months –
subcommittee• Community
Assessment• Scope & Role• Education• Sustainability/Payers• To come: Data,
Protocol, Regulatory, Advertising
Different Models -
proposed
Community Integrated Paramedicine• Community Paramedicine Programs
• Driving force is an EMS agency, possibly a medical control authority with a community focus.
• Connecting dots, reducing utilization
• Mobile Integrated Health Programs• Driving forces is a hospital, health
plan, or a stand alone• 30 day readmission avoidance
Community Assessment
• Intuition - Gaps• Available Data – only if
you ask the right questions
• Resources• Who knew?• 211• Referral is a two
way street
Scope and Role
• Medication Reconciliation• Home Safety Checks• Social Barriers• First line antibiotics• Foley catheters• Wound Care• IV Starts/Changes
• Alternate Destination Transports
• Post-Discharge Follow-Up• Chronic Disease
• Episodic assistance• Education• Post-discharge monitoring
Education
Standardized Curriculum
Approved by MDHHS
May include more than one level or provider
Required continuing education
Sustainability
0098-Treat no Transport
Hospital Savings
Partner Programs
Primary Care Physicians
Private Insurance
Medicare/Medicaid
Data, Protocol, Regulation, Advertising
Data – 40 National measures
Protocol – Established and expanding, formalizing to match scope & role
Regulation –Endorsement/Certification/Licensure
Advertising – How do we connect?
National Consensus Conference on Community Paramedicine: Summary of an Expert Meeting
• Education and Expanded Practice Roles.
• Integration of CP Providers with Other Health Providers.
• Medical Direction and Regulation.
• Funding and Reimbursement.
• Data, Performance Improvement, and Outcome Evaluation.
• Community Paramedicine Research Agenda
What does CP Education Look Like?
• Professional Boundaries• Interactions• Social Determinants of Health• Cultural Competence• Pathophysiology• Lab Values• Plan of Care
• Chronic Diseas Mangement• Mental Health• Communication Strategies• Hospice and Palliative Care• Nutrition• Pharmacology• Immunizations
Chronic Disease
• Iceberg Analogy• Point of Care Testing
Monitoring
• Medication Reconciliation• Referral• Medication Administration
Management
Patient Education
Equipment & Skill Set Snapshot
Electronic Stethoscope with
Bluetooth
Ophthalmoscope
Otoscope
Peak Flow MeterWound
Decontamination and Cleaning
Closure of Wound Edges & Dressing
Tracheostomy Care
PICC Line Care CPAP
I-Stat
PBT
What can we do for you ?
Think outside of the box
Examples of filling the gap
Examples of safety net
Non-competition
Thoughts from Today
• Jon Ramey/Georgia Asthma Coalition• Arrest story – they know it, over and over.• Financial aspect & environmental triggers – see things that they can’t or won’t
articulate
• Robert Wahl/Chronic Disease Epidemiology• We use your data – thank you!• We see different
• Lisa Knight-Urban League• Vodka, toothbrush, water bottle, E without a stop light• One small piece in the wreckage